Unfortunately, summer is known as "trauma season" at Harborview when we see a peak of youth injuries, especially head trauma. In addition to summer recreational activities, youth around our area are starting camps and early practices for the fall sports season. So, this is an opportune time to review concussions, a very hot topic in pediatrics (and society-at-large, for that matter). We as pediatricians are increasingly called upon to address these injuries in clinic and clear youth for return to activities. Below are teaching materials for this week. Also check out R3 Emilie Weigel's great RCP review on concussion which she presented this month.
Key take-home points for concussions:
- Epidemiology: Concussion accounts for an estimated 8.9% of high school athletic injuries, and this is likely a low estimate due to underreporting. Football has the highest incidence of concussion, but girls have higher concussion rates than boys do in similar sports (possibly due to higher reporting). Loss of consciousness occurs in about 10% of concussions-but may signal a more severe injury.
- Concussion definition: complex pathophysiological process affecting the brain with 5 common features:1) induced by traumatic forces to the head, either directly or indirectly, 2) rapid onset of short-lived neurologic impairment that resolves spontaneously, 3) may have neuropathological changes but these are functional more than structural, 4) a graded set of clinical symptoms which resolve following a sequential course, however, symptoms may be prolonged, and 5) no structural abnormality on standard neuroimaging.
- Work-up should include history of event including loss of consciousness, amnesia, prior injuries, and current symptoms. Assess 4 broad categories of symptoms–physical, cognitive, emotional, and sleep. Be sure to ask parents, not just patients. Also review any assessments done at the time of injury (e.g. SCAT3, etc). You can also complete these in the office, such as the SCAT3 version used at HMC. Physical exam should include GCS scoring, and examinations of the head, neck, pupils, and a full neurologic exam including gait, balance, coordination, and orientation.
- Imaging: CT scans are not routinely indicated unless there are significant symptoms including severe headache, vomiting, worsening symptoms, or neuro changes suggestive of more serious injury. See HMC algorithm for determining need for CT after head injury. This HMC algorithm is based on the national Pediatric Emergency Care and Research Network (PECARN) criteria. This helps avoid unnecessary imaging, while covering those who still need it.
- Treatment: Fortunately, most people recover from concussions within 7-10 days, but youth may take longer than adults. After concussion diagnosis, we recommend a gradual return to play with 24 hours at each stage (e.g., rest, walking, light aerobic activity, higher exertion, practice, scrimmage, games)-this generally means about a week before full return. Do not progress if there are symptoms at any stage. Here's a handout to use that reviews return to play. We should also recommend gradual return to learning, and youth may need accommodations before returning to full cognitive performance, such as test-taking.
Check out resources from our sports medicine experts here.
Have a great week!